Innovation summary

There is an epidemic of type 2 diabetes related to the epidemic of obesity with people of lower socio-economic status at higher risk. 3DFD integrates medical, psychological and  social care for patients with persistent suboptimal glycaemic control and aims to improve glycaemic control, quality of care and patient-reported outcomes as well as reduce psychological distress, short and long term health service user costs.

Impact summary

  • Approximately 400 people have been referred to 3DFD throughout the two pilot stages
  • There was a significant improvement across medical and psychological markers, with significant reductions in glucose marker HbA1c, that remained table at the 2 year follow up
  • The service costs US $160k per year per borough. The first pilot incurred a savings of approximately $90

"Although there is growing recognition of the importance of psychological care in long term conditions such as diabetes, this is the first service in the UK which has integrated social interventions as well as psychological care into diabetes care for people struggling with managing their diabetes in an area of severe socio-economic deprivation and marked health inequalities." 

- Professor Khalida Ismail

Innovation details

3DFD is set in South London, UK, in the inner-city boroughs of Lambeth and Southwark, areas with high levels of deprivation and ethnic diversity with a combined resident population of 600,000 .The prevalence of type 2 diabetes is 4% ( 24,000 people).

The service consists of a liaison psychiatrist and 2 community workers from ThamesReach, a local third sector social welfare organization originally designed for supporting homeless people.

The care pathway is embedded into routine diabetes in the community or hospital diabetes services, depending on where the patient prefers to receive care.

  • GPs refer directly or via the community teams for intensive diabetes management after completing a simple referral form allowing identification of psychological and/or social problems and poor glycaemic control
  • Following triage, the interventions include:
    • brief focused psychological treatments such as cognitive behavior therapy, counselling, and motivational interviewing
    • optimizing psychotropic medication
    • interventions targeting social problems, such as poor housing, debt management, literacy, carer support, domestic violence and childcare, occupational rehabilitation
    • patient-led case conferences to integrate psycho-social care with diabetes care by addressing barriers to diabetes self-care, risk assessments and patient safety
  • Once the patient has made progress, 3DFD supports the return of the patient to routine diabetes care

Key drivers

Combination intervention

3DFD is a combination of social, psychological and medical interventions. Although there is growing recognition of the importance of psychological care in long term conditions, such as diabetes, this is the first service, in the UK, which has integrated social interventions as well as psychological care into diabetes care for people struggling with managing their diabetes.

Usually most integration or collaborative models only address 2 dimensions – the mental and physical. This program ensures that in chronic disease management the social dimension of care is also addressed.

Integration

Successful integration has taken place across 3 sectors: primary care, secondary care and the third sector. Unlike traditional liaison psychiatry services, we are not limited to the hospital – 3DFD is integrated with the community diabetes teams and primary care and with community resources and services via the third sector, so that the patient has access to the full range of treatment, regardless of the site of his/her diabetes care.

Discovery of resources

We learnt that there is a wealth of experience, knowledge and skills in non-statutory organizations that health care models are simply not aware of and therefore not accessing. These have been incorporated into the program.

Patient-led management plans

The patient-led case conference was particularly valuable in increasing the patient's self-esteem and promotion their self-efficacy of diabetes self-case. By letting the patient lead the case conference and other aspects of their care, it allowed us to acquire an in-depth learning of their difficulties thus improving the patient-care provider alliance. It allowed the patient to return to, and engage with, mainstream services as they improved.

Challenges

Setting up cross-sector teams

Care providers are used to working according to their own professional training and experience, the values of the sector they come from and the work culture of their organization. In assembling a team from mental health, acute medicine and the third sector, we learnt the importance of respecting and integrating these variations. We learnt that this required patience, tolerance, respect, willingness to learn and share one’s own knowledge, joint training for team members, and developing a common goal.

Diplomacy

It is not enough that the idea is a good one and that opinion leaders and key players approve of it. A learning point is the need for constant and clear communication streams at multiple levels across the sector boundaries, across organisations and across policies. This is important in the current climate of economic and political uncertainties regarding commissioning of services and loss of local government funding for our third sector partners, ThamesReach.

Professional ignorance

Original plans for the professional needs of the program were not efficient and had to be re-examined. For instance, in the original planning there was funding for a full-time social worker and only session time from the third sector support worker. We learnt very quickly our definition of social care was wrong and the social care workforce planning needed to be reversed.

‘Hard-to-reach’ are not necessarily hard-to-reach

This patient group’s perception of the services on offer through this program were discovered to be an important factor that influences their engagement and this observation fed into the layout and development of the services.

Funding

Ultimately, the biggest challenge was securing funding to ensure the continuation of the project.

Continuation

This model has been replicated in another borough in North London, by the North-West London and Hillingdon NHS Foundation Trust, and will be used by .

We have created a model ready for testing in other conditions with built-in clinical pathway, research portfolio and training and education activities, which the South London Integrated Care initiative are planning to roll out.

The Clinical Commissioning Groups have commissioned extension of pilot 2 with a view to scaling up as a substantive commission based service. The second phase of development is well underway. 3DFD is now being tested in the community diabetes teams in Lambeth and Southwark, comparing outcome data with usual care in Lewisham. Since September 2012, we have recruited an additional 280 people.

As a result of this generic diabetes and mental health service, we have identified specific areas for further development. For instance, people with diabetes and eating disorders are a special high risk group which manifestly fall between the acute and mental health trusts.

Partners

Funders

The first pilot

  • NHS London Regional Innovation Fund

The second pilot

Evaluation

  • Lambeth and Southwark Clinical Commissioning Group have commissioned US $80k to contribute to support a further 6 months evaluation

Delivery partners

This is partnership between the King’s Health Partners Academic Health Science Centre and the local primary care services:

Hospitals

Primary care

Academic

Evaluation methods

Design

A non-randomized case comparison design is being used with cases being patients referred to 3DFD from Lambeth and Southwark boroughs. Comparison patients are patients resident in the adjacent borough of Lewisham who meet the referral criteria but do not receive 3DFD. We could not recruit comparison patients from Lambeth and Southwark as the 3DFD service was integrated into all diabetes services and therefore potentially available to all residents with poorly controlled diabetes. To minimize contamination we selected comparison patients the adjacent borough of Lewisham who came from a similar socioeconomic and geographical setting with otherwise broadly similar diabetes services without the 3DFD model.

Measures

At referral and at 12 months the following data is collected as part of the evaluation process:

Bio-medical

    • HbA1c
    • blood pressure
    • serum cholesterol
    • body mass index (BMI)
    • renal function
    • history of diabetes complications
    • medications.

Psychological measures

    • Depressive symptoms-Patient Health Questionnaire-9 (PHQ-9)
    • Anxiety symptoms-Generalized Anxiety Disorder (GAD-7)
    • Diabetes related distress-Diabetes Distress Scale (DDS)
    • Quality of life-Short Form 12 (SF-12)
    • Social functioning -Outcome Star developed by Thamesreach which is a series of visual analogues that capture patient reported outcomes

Service utilization

    • unscheduled care as measured by inpatient admissions and emergency department attendances
    • scheduled care as measured by non-attendance rates at diabetes clinics and for retinal/foot screening;
    • Client Service Receipt Inventory (CSRI) which is a self-report measure of service use in the previous 6 months

Cost analysis

Collaboration with the Centre for the Economics of Mental and Physical Health at King’s College London is underway to conduct a detailed cost-benefit and cost-effectiveness analysis using short-term outcomes and predictive modelling to estimate savings that can be made over the long term.

Cost-effectiveness will be assessed by combining the costs calculated from records with quality-adjusted life years (QALYs) derived from the measure of quality of life form.

Cost of implementation

The service costs approximately USD $160k per year per borough. In the first pilot, it saved USD $92.3K directly in the first year by reducing bed days and A&E presentations over the following 12 month period, and preliminary modelling suggests projected savings of US $160k year-on-year in delaying or preventing diabetes complications. The conclusion is that 3DFD saves the NHS money in the medium to long term.

Impact details

In the first pilot (September 2010 to March 2012), 119 people were referred over 18 months. In the second pilot we have received 280 referrals in the first 10 months.

The people referred were at high risk of developing diabetes complications. The average age was 46.2 years; there was twice as much type 2 diabetes; the majority of referrals were from ethnic minorities , with 43% black and 19% Asian, and high depression rates were recorded.

Clinical outcomes in the patients from the two pilots included:

  • Clinically significant reductions in HbA1c that were three times greater than that of a new diabetes drug on the market
  • Trend in improvements in blood pressure control , lipid control, weight control, levels of depression and levels of anxiety
  • Qualitative evidence of patient satisfaction
  • Cost savings

As pilot 2 is in progress data collection will continue with more outcomes expected at the end of 2013.

Research

Multimedia

Reports
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United Kingdom of Great Britain and Northern Ireland

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